Factors associated with cutaneous colonization of Mucormycetes in diabetic and non-diabetic individuals

This study was conducted to assess factors associated with cutaneous colonization of Mucormycetes in diabetic and non-diabetic individuals. A total of 800 swab samples from 200 participants including 100 diabetics and 100 non-diabetics were collected from four different body sites: (1) the forehead, (2) nasal cavity, (3) hands and (4) feet. Fungal isolation, fungal identification and antibiotic sensitivity tests were performed on the isolates. Overall, 12.0 % of the participants showed Mucormycetes colonization while the commonest fungal isolates were Mucor Species (Spp.). followed by Rhizopus spp. Diabetics had a 11 times higher odds of colonization compared to non-diabetics. The majority of the isolates were resistant to itraconazole; however, all isolates were sensitive to amphotericin B. A significant association was observed between profession and Mucormycetes (P=0.03) with significantly higher colonization in retired people compared to business people. Higher odds of colonization were demonstrated among older ages, lower class status and individuals with prolonged contact time with soil.


INTRODUCTION
Admist recent Coronavirus Disease 2019 (COVID-19) pandemic, the public became more aware of mucormycosis, but this is not a new disease.Mucormycetes are ubiquitous and spread via inhalation and inoculation [2].Mucormycetes cause a serious but rare fungal infection called mucormycosis (previously called sygomycosis) [3].These fungi cause mild to life-threatening disseminated infections depending upon the host's immune condition, site of colonization and variant of the fungus [2].Conditions such as malignancies, diabetes, trauma, burns, transplantation, malnutrition, immunosuppressive conditions and therapies are associated with a high risk of infection [4,5].Reported mortality rates in disseminated, pulmonary and sinus infections are 96.0,76.0 and 46.0 %, respectively [6].
Diabetes is an endocrine condition in which blood glucose levels become elevated, which results in impaired immunological function that offers an ideal environment for fungal growth [7,8].Globally, the prevalence of diabetes has been rising rapidly, especially in developing countries.In Nepal, the prevalence of pre-diabetics and diabetics is 19.5 and 9.5 %, respectively, with roughly 15.0 % of diabetic individuals living in metropolitan areas [9].Nepal is lacking adequate facilities for fungal infection diagnostics and lacks optimum understanding regarding fungal diseases.This means that diabetics are missing prompt diagnosis of any possible fungal infection.Mucormycosis is a rare fungal disease among diabetics, but it causes life-threatening complications if not treated in a timely manner [10].Social factors such as socio-economic status, occupation, age and level of education level can contribute to colonization of these fungi among diabetics [2].Research on Mucormycetes has mainly focused on mechanisms involved in infection, and there are limited studies regarding its asymptomatic colonization among immune compromised individuals.The present study was designed to investigate the status of asymptomatic colonization of Mucormycetes in diabetic and non-diabetic individuals.It is the first study in Nepal to investigate the role of social factors in fungal colonization.

Study design and sample collection
A case-control study was conducted in Kathmandu Metropolitan area, Nepal, between January and July 2022.A total of 200 participants (100 diabetic and 100 non-diabetic), aged 18 years and above, were enrolled.Swab samples were collected from five different sites such as the forehead, nasal cavity, hands and feet.Samples were then transported to the Department of Medical Laboratory Technology within 1 h, maintaining a cold chain.Participants who were on antifungal medication and had symptomatic fungal infection during the sampling period were excluded.

Fungus isolation, identification and antifungal testing
Swab samples were inoculated on Sabouraud Dextrose Agar (Hi-Media) containing chloramphenicol at 50 mg l −1 and were incubated aerobically for 3-5 days at room temperature (25-30 °C).Identification of Mucormycetes was carried out based on colony morphology and microscopic examination, using the scotch tape method and the tease mount preparation method.Isolates were transferred to Sabouraud Dextrose Broth (Hi-Media) to obtain turbidity equivalent to McFarland standard 0.5.The preparations were then inoculated on Mueller Hinton Agar (Hi-Media) plates using a lawn culture technique for antifungal susceptibility testing.Interpretation of results was carried out following guidelines of the Clinical and Laboratory Standards Institute (CLSI) [11].Commercially available antifungal discs used were amphotericin B (10 µg; Hi-Media), voriconazole (1 µg; Hi-Media) and itraconazole (1 µg; Hi-Media).Candida krusei (ATCC 6258) and Aspergillus flavus (ATCC 204304) were used as quality control strains.

Data analysis
The obtained data were entered into and analysed using Statistical Package for the Social Sciences (IBM) version 21.Descriptive and analytical statistics were performed.Fischer's exact test was used to determine the association between independent variables and fungal colonization among both groups considering a P-value of <0.05 as statistically significant.

RESULTS AND DISCUSSION
Mucormycosis is a rare fungal disease with a high mortality rate.The number of cases in 2010 was found to have increased more than 5.5-fold when compared with cases in 1990 [12].The disease is often associated with underlying health conditions such as diabetes, organ transplantation, immunosuppressive status and cancer.Annually, the incidence of mucormycosis is about 1.7 cases per 1 000 000 individuals [13].During the recent Severe Acute Respiratory Syndrome Coronavirus-2 (SARS-CoV-2) pandemic, mucormycosis was mainly reported in patients with uncontrolled hyperglycaemic conditions [14].This association can be explained by the fact that an uncontrolled diabetic condition leads to dysfunction of the immune system, which leaves patients more susceptible to colonization by fungi such as Mucormycetes.The prevalence of diabetic individuals in low-and middle-income countries is higher and rapidly increasing in comparison with that in high-income countries [15,16].
Mucormycetes were found in 12.0 % (24/200) of the participants, 22 of whom were diabetics and two were non-diabetics.Therefore, the rate of fungus colonization in diabetics is 11 times higher than that in non-diabetics.In diabetics, Mucor spp. was the predominant fungus, followed by Rhizopus spp., Rhizomucor spp.and Syncephalastrum spp., respectively.On the other hand, in non-diabetics, only Mucor spp. was isolated (Table 1).Our previous study also found that only diabetics were positive for Mucor spp.and Rhizopus spp.colonization [17].A retrospective study that analysed 6 years of data on Mucormycetes in Australia found that 32.0 % of cases had invasive fungal disease and 56.0 % were colonized mainly by Rhizopus spp., Rhizomucor spp.and Mucor spp.[18].Another prospective study found 388 proven/probable Mucormycosis cases, of which Rhizopus arrhizus, Rhizopus microspores, Apophysomyces variabilis and Rhizopus homothallicus were reported in descending order of prevalence among uncontrolled diabetics [19].Similarly, another study noted that Rhizopus oryzae was the main organism in patients with diabetes [6].Diabetics have diminished chemotaxis and phagocytosis activity, increased iron availability and a lower pH that facilitate mucormycosis development [20].This leads to higher vulnerability to severe complications related to mucormycosis.Common clinical conditions include cavernous sinus thrombosis, disseminated infection, periorbital destruction, palatine ulcers and osteomyelitis that can lead to death of the patient if not treated early and appropriately [4,9].We found that the colonization of Mucormycetes was higher in female participants.Interestingly, among non-diabetic participants, only females were positive for colonization.In addition, colonization is often associated with socio-economic

Continued
status, profession and contact with soil.We noted that colonization decreases with an increase in level of education: uneducated participants showed the highest colonization, followed by those of primary, secondary and school leaving certificate education.Furthermore, retired participants had a higher colonization rate than working participants.Here, the elderly age group (>60 years) seemed to have a 19 times greater risk of Mucormycetes colonization than adults.A statistically significant relationship (P=0.03) was observed between participants' profession and fungal isolation, where retired people were found to be at higher risk of fungal colonization.It has previously been observed that immunosenescence starts in old age, and pathogens can easily colonize and establish infection [21].The immune system gradually weakens with age, conferring decreased immune cell production (B-cells and T-cells) and function, allowing pathogens to colonize easily and cause illness [22].
In addition, those who frequently come into contact with soil had a three times higher odds of colonization than those with less contact.Mucorales are present throughout the environment, growing in organic substances such as food, dead plants and animal waste materials.Therefore, spores of these pathogens can enter the body through inhalation and skin contact.This may also cause cutaneous mucormycosis without underlying conditions.We have found that colonization mainly occurred in the feet, followed by the nasal cavity, forehead and hands, indicating inadequate hygiene among people working in the fields.A recent study found that 22.2 % of cases of asymptomatic airway colonization were due to Mucorales [23].The fungi are transmitted mainly via inhalation of spores, which are further deposited in the paranasal sinuses.Germination and establishment of fungi are favoured by the moist surface of the nasal cavity [24].Similarly, individuals of lower and upper lower socio-economic status were relatively more prone to colonization than those with higher incomes.A lack of health education regarding diabetes and mucormycosis, inadequate sanitization, and low socio-economic status can contribute to mucormycosis among diabetics.
A study found that Mucor spp.and Rhizopus spp.isolates from environmental samples were resistant to voriconazole and itraconazole [25].

Reply to reviewer's comments
Dear Editor, Thank you so much for your and the reviewer's comments on our manuscript.We have carefully revised the manuscript in response to the extensive and insightful comments we received.We are pleased that there is interest in the topic and are grateful for constructive comments.
We have addressed the comments point by point.Appended below, please find the list of all reviewer's comments along with our response to each point.
We hope this revised version will be suitable for consideration.

Bhuvan Saud
Corresponding author

Reviewer 1
Comments to Author:This is an interesting paper dealing with colonization by Mucorales in diabetic and no diabetic people.However, some points that needs some clarification before further review.
1. Discussion: It would be very important to improve the discussion separating colonization from infection by Mucorales.How significant are the colonization data in comparison with previous studies?Is the study inedited?There is no earlier data considered for the discussion?These points are not well explained in the Discussion section.
Reply:Discussion has been edited separating infection from colonization.We have cited relevant articles though limited studies have been published related to Mucorales colonization.Also, most of the published articles were case studies and similar studies like ours hasn't been publishes yet in PubMed, Hinari, Google Scholar, Medline, etc. And, this study is an original research work which is submitted under short communication in the journal.
2. The discussion should be better organized, addressing the results, and keeping the interpretations limited to the type of study.For example, the sentence "Early diagnosis, management and rapid intervention, advance heath care system, and specific guidelines are paramount for substantially reducing morbidity and mortality associated with Mucormycosis." is out of scope.In my opinion, the Discussion would benefit from a more focused scope on colonization and risk of infection.
Reply:Thank you for the comment.Here, result and discussion section have been merged for the better organization, clarification of the results and comparative interpretation.Also, above mentioned sentence has been removed.And, current discussion section is mainly focused on colonization and risk of infection.
3. The authors should inform the document they used or adopted parameters for concluding resistance of susceptibility of Mucorales isolates, since no cutoffs are defined for this fungal group.
Reply:Thank you for your comment.Clinical and Laboratory Standard Institute (CLSI) M44-guideline has been followed for anti-fungal susceptibility testing and results were interpreted accordingly.The CLSI-M44 guideline has been cited in methodology section of the manuscript.
4. In Results and Discussion, I recommend clarifying which profession presented the highest risk to be colonized with Mucorales, to improve understanding.
Reply:Thank you for your suggestion.Comment has been addressed.Retired participants had the highest level of the colonization than working participants.
5. The conclusion did not be supported by the results obtained in this work since risk factors for colonization with no statistical strength were used for conclusions.
Reply:Thank you for your comment.Conclusion has been paraphrased as in "Our research findings revealed that a statistical significant result was seen between profession and Mucormycetes colonized individual (p-value=0.03)with significantly higher colonization in retired people in comparison to businesspersons.In addition, individuals that spend more time in soil, higher age (>60 yrs.), lower class of individuals are at a greater risk of Mucorales colonization." 6.There are many syntaxes and writing errors (e.g.Participants with previously diagnosed fungal infection, those under antifungal or immunosuppressive treatment excluded OR Swab samples inoculated on Sabouraud dextrose agar containing chloramphenicol 50 mg/l and then incubated aerobically for 3-5 days at room temperature (25-30ºC).
B was sensitive to all isolates OR all isolates were susceptible to Amphotericin B? The English would need extremely extensive editing.
Reply: Thank you for your comment.Syntaxes and writing errors have been corrected by English professionals.Also, sentences have been corrected as follows in the manuscript: "Participants who were under antifungal medication and symptomatic fungal infection were excluded." "Swab samples were inoculated on Sabouraud Dextrose Agar (Hi-media, India) containing Chlorampheni.. " "all isolates were sensitive to Amphotericin B". 7. Finally, the statistical analysis may be more robust.With so many confounding conditions in colonized patients, the analysis could provide misleading results.E.g. it would not be surprising that retired people got more colonization, and may just reflect the more soil exposition of this population.
Reply:Thank you for your comment.Statistical analysis has been done as per reviewer's suggestion.Now, Fischer's test was adopted instead of Chi-square test.Also, in regards to "retired people got more colonization, and may just reflect the more soil exposition of this population" correction has been made in the manuscript.

Minor concerns:
Line 52.What is the meaning of "neon disease"?Reply:Thank you for your comment.Correction has been made in the manuscript; neon diseases has been replaced by new diseases.
Line 79.Unit system must be corrected."ml" is wrong.According to International System of Units, "L" is for liters and "l" is for length (this was accepted as an alternative symbol for liter in 1979).All manuscript must be reviewed.The European Union has a directive banning non-SI markings after 31 December 2009 on any goods imported into the European Union, which will to include manuscripts.
Reply:Thank you for the comment.Correction has been made in the manuscript."50 mg/L... " Lines 81-83.The methodology for testing antifungal drugs needs references for both: perform the essays and for interpret results.Some imprecisions (e.g.undiluted suspensions of the isolates) should be avoid to improve understanding.
Reply: Thank you for your comment.Reference has been added and the correction has been made.As in "Result interpretation was carried out adopting the Clinical and Laboratory Standard Institute (CLSI) M44-guideline.Commercially available antifungal discs used were Amphotericin B (10µg) (Hi-media, India).. ".Imprecisions have been fixed.
Use capital letter in Mueller Hinton and in Sabouraud since they refer people names.
Reply:Thank you for flagging this issue.Necessary correction has been made in the manuscript.Line 84.Manufacturer names for commercially available antifungal discs should be provided.
Reply:Thank you for your comment.Manufacturer name has been added in the manuscript as in: "Amphotericin B (10µg) (Hi-media, India), Voriconazole (1µg) (Hi-media, India) and Itraconazole (1µg) (Hi-media, India).. " Line 97.Please, clarify the relation between the percentages in "The prevalence of mucormycetes was 12.0% (24/200)  Reply: Thank you for your comment.The correction has been made."the isolates were sensible" Line 108.The nasal samples have no relatively higher risk of of getting infection.Please, re-phrase.
Reply:Thank you for your comment.It has been removed.Line 120.Who is "They"?Moreover, no reference was cited to support that in middle-income countries there is no proper education system, health care facilities, socio-economic status and adequate knowledge about fungal infections.
Reply:Thank you for your comment.The correction has been made and cited."Evidently, prevalence of diabetic individual is higher in low-income and middle-income countries and their number rapidly surging than in high-income.. " In Table 1: -Please, correct the columns titles: Overall values n (%) Reply:Thank you for your comment.The correction has been made.
-On the footnote, define what is the acronym "Ref ".Is it variable of reference?
Reply:Thank you for your comment.The correction has been made.

Comments -Reviewer 2:
Methodological rigour, reproducibility and availability of underlying data 1.The methods are currently insufficient to be able to reproduce the analysis.For example, for antifungal susceptibility testing, there is no description of quality control strains or other controls being used.The different methodologies also need to be separated and grouped under descriptive subheadings in the methods section.
Reply: Thank you for your comment.The comment has been addressed.Candida krusei(ATCC 6258) and Aspergillus flavus(ATCC 204304) were used as quality control strains which now have been mentioned in the manuscript.Also, separate sub-headings have been added in the method section.
2. Regarding the statistical analysis, Chi-square tests are appropriate where sample numbers are large.Where sample numbers are small (<5), as is the case for several variables used in this study, it is more appropriate to use Fisher's exact tests.Statistical analysis for these samples could be repeated using this method.
Reply:Thank you for your suggestion.Fisher's exact test has been used.Presentation of results / how the style and organization of the paper communicates and represents key findings 3. The sampling results are sufficiently presented in Table 1, however, a footnote should be added at the bottom explaining how the odds ratios and P-values were generated and what they refer to.
Reply:Thank you for your comment.Comment has been addressed.'*'-significant value for p-value<0.05.#-Fischer's Exact Test; 4. Additionally, the antifungal susceptibility testing results are mentioned in the text of the results, but the actual values are only presented in the supplementary material.As this is one of the more interesting results of the paper, this should be taken out of supplementary and added as Table 2.These results would also be greatly improved by the inclusion of the actual MIC results for each isolate.
Reply:Thank you for your comment.The comment has been addressed.We have added the data from the supplement document as Table 2.But in this study we haven't calculated MIC due to lack of anti-fungal drugs.
Literature analysis or discussion 5.Given the brevity of the article and the fact that large amounts of the discussion section currently mostly detail results of the study, it would be preferable for these sections to be combined together as a single results and discussion section rather than as separate sections.
Reply:Thank you for your comment.Result and discussion have been merged as single section.

Any other relevant comments
The manuscript currently suffers from poor English and needs to be edited for grammar and clarity before it will be in a publishable state.The abstract in particular needs rewriting as many sentences do not appear to be complete.

Here are two examples:
Reply:Thank you for your comment.All the required corrections have been made.
52 "…not a neon disease."This does not make sense, is this supposed to say "not a new disease"?Reply:Thank you for your comment.Neon word is replaced with new."nonetheless, it is not a new disease." Line 68 "Therefore, this study designed to investigate to factor associated with…" There are several mistakes in this sentence which make it difficult to read.Comments: Dear Dr Saud, Thank you for your submission.The reviewers have indicated that the work, while interesting and valuable, requires revisions both typographic and potentially methodological.Please address their comments and if deemed necessary, the journal provides a discount translation service that may be of use.This study would be a valuable contribution to the existing literature.The reviewers have highlighted major concerns with the work presented.Please ensure that you address their comments.Please include more rigour criteria and resources in your methods section, as highlighted by the SciScore reports.Including RRIDs and negative statements to explain why things were not performed should increase the rigour and reproducibility of your work.You can find tips on how to improve your article here: https:// sciscore.com/ reports/ Core-Report.php The language used is poor, which can cause ambiguity at times.Please carefully rewrite it.We offer a discounted translation service, Editage (https://www.editage.com/; see https://www.microbiologyresearch. org/ prepare-an-article# 13 for more information).Best wishes, John.Comments: This is an interesting paper dealing with colonization by Mucorales in diabetic and no diabetic people.However, some points that needs some clarification before further review.It would be very important to improve the discussion separating colonization from infection by Mucorales.How significant are the colonization data in comparison with previous studies?Is the study inedited?There is no earlier data considered for the discussion?These points are not well explained in the Discussion section.The discussion should be better organized, addressing the results, and keeping the interpretations limited to the type of study.For example, the sentence "Early diagnosis, management and rapid intervention, advance heath care system, and specific guidelines are paramount for substantially reducing morbidity and mortality associated with Mucormycosis." is out of scope.In my opinion, the Discussion would benefit from a more focused scope on colonization and risk of infection.The authors should inform the document they used or adopted parameters for concluding resistance of susceptibility of Mucorales isolates, since no cutoffs are defined for this fungal group.In Results and Discussion, I recommend clarifying which profession presented the highest risk to be colonized with Mucorales, to improve understanding.The conclusion did not be supported by the results obtained this work since risk factors for colonization with no statistical strength were used for conclusions.There are many syntaxes and writing errors (e.g.Participants with previously diagnosed fungal infection, those under antifungal or immunosuppressive treatment excluded OR Swab samples inoculated on Sabouraud dextrose agar containing chloramphenicol 50 mg/l and then incubated aerobically for 3-5 days at room temperature (25-30ºC).Amphotericin B was sensitive to all isolates OR all isolates were susceptible to Amphotericin B? The English would need extremely extensive editing.Finally, the statistical analysis may be more robust.With so many confounding conditions in colonized patients, the analysis could provide misleading results.E.g. it would not be surprising that retired people got more colonization, and may just reflect the more soil exposition of this population.Minor concerns: Line 52.What is the meaning of "neon disease"?Line 79.Unit system must be corrected."ml" is wrong.According to International System of Units, "L" is for liters and "l" is for length (this was accepted as an alternative symbol for liter in 1979).All manuscript must be reviewed.The European Union has a directive banning non-SI markings after 31 December 2009 on any goods imported into the European Union, which will to include manuscripts.Lines 81-83.The methodology for testing antifungal drugs needs references for both: perform the essays and for interpret results.Some imprecisions (e.g.undiluted suspensions of the isolates) should be avoid to improve understanding.Use capital letter in Mueller Hinton and in Sabouraud since they refer people names.Line 84.Manufacturer names for commercially available antifungal discs should be provided.Line 97.Please, clarify the relation between the percentages in "The prevalence of mucormycetes was 12.0% (24/200) of which 22.0% (22/100)…" Line 104.What is the meaning of "types"?Line 105.Prefer sensible, instead of sensitive.Line 108.The nasal samples have no relatively higher risk of of getting infection.Please, re-phrase.Line 120.Who is "They"?Moreover, no reference was cited to support that in middle-income countries there is no proper education system, health care facilities, socio-economic status and adequate knowledge about fungal infections.Line 123.Please, clarify if the data is related to colonization or infection by Mucorales in diabetic patients.Line 131.Mucormycosis is misspelled Line 145.Please, remove "In this study" In Table 1 The methods are currently insufficient to be able to reproduce the analysis.For example, for antifungal susceptibility testing, there is no description of quality control strains or other controls being used.The different methodologies also need to be separated and grouped under descriptive subheadings in the methods section.Regarding the statistical analysis, Chi-square tests are appropriate where sample numbers are large.Where sample numbers are small (

Reply
of which 22.0% (22/100)…" Reply:Thank you for your comment.It has been corrected."Prevalence of Mucormycetes was 12.0% (24/200) of which 22 were isolated from diabetes and 2 from non-diabetic participants." Line 104.What is the meaning of "types"?Reply:Thank you for your comment.The correction has been made.Line 105.Prefer sensible, instead of sensitive.
123.Please, clarify if the data is related to colonization or infection byMucorales in diabetic patients.Reply:Thank you for your comment.The correction has been made."In this regard, we therefore designed our study to investigate the status of asymptomatic colonization of Mucormycetes in diabetic and non-diabetic individuals.. " Line 131.Mucormycosis is misspelled Reply:Thank you for your comment.The correction has been made.Line 145.Please, remove "In this study" Reply:Thank you for your comment.The correction has been made.

: 1 Editor
Thank you for your comment.The sentence has been rewritten."Therefore, this study investigates prevalence and factors associated with colonization of Mucormycetes in diabetic and non-diabetic individuals residing in Kathmandu, Nepal." VERSION recommendation and comments https://doi.org/10.1099/acmi.0.000495.v1.5 © 2022 Munnoch J.This is an open access peer review report distributed under the terms of the Creative Commons Attribution License.John Munnoch; University of Strathclyde, SIPBS, UNITED KINGDOM, Glasgow Date report received: 19 December 2022 Recommendation: Major Revision

Reviewer 2
recommendation and comments https://doi.org/10.1099/acmi.0.000495.v1.4 © 2022 MELHEM M. This is an open access peer review report distributed under the terms of the Creative Commons Attribution License.MARCIA DE SOUZA CARVALHO MELHEM MELHEM; Instituto Adolfo Lutz, Mycology, Avenida Giovanni Gronchi, 4720, São Paulo, BRAZIL https://orcid.org/0000-0002-1335-8808Date report received: 13 December 2022 Recommendation: Major Revision :-Please, correct the columns titles: Overall values n (%) -On the footnote, define what is the acronym "Ref ".Is it variable of reference? 5. Any other relevant commentsPlease rate the manuscript for methodological rigour Very poorPlease rate the quality of the presentation and structure of the manuscript PoorTo what extent are the conclusions supported by the data?Partially supportDo you have any concerns of possible image manipulation, plagiarism or any other unethical practices?NoIs there a potential financial or other conflict of interest between yourself and the author(s)?NoIf this manuscript involves human and/or animal work, have the subjects been treated in an ethical manner and the authors complied with the appropriate guidelines?YesReviewer 1 recommendation and comments https://doi.org/10.1099/acmi.0.000495.v1.3 © 2022 Fernandes K.This is an open access peer review report distributed under the terms of the Creative Commons Attribution License.Kenya Fernandes; The University of Sydney, AUSTRALIA https://orcid.org/0000-0002-2912-4360Date report received: 03 November 2022 Recommendation: Major Revision Comments: In this Short Communication, Saud et al. present sampling and antifungal susceptibility data for mucoromycetes isolated from diabetic and non-diabetic individuals.Methodological rigour, reproducibility and availability of underlying data

Table 1 .
Distribution of fungal isolates among study individuals and its association with

Table 2 .
Antifungal resistance pattern of clinical isolatesPeople with diabetes are highly prone to colonization by cutaneous mycoses.A logistic regression analysis concluded that soil contact, old age and lower socio-economic status contributed to colonization.It is necessary to promote hygiene knowledge and awareness among diabetics to prevent any future serious complications from such infection.Likewise, a continuity of care programme for diabetics can help prevent uncontrolled diabetes and improve quality of life, which can further contribute to preventing the dissemination of mucormycosis infection.